Treating depression with electroconvulsive therapy.
Many myths exist surrounding the use of electroconvulsive therapy (ECT), which is a procedure that induces a seizure in the brain through an application of an electric current through the scalp. Although ECT is not a first-line treatment (and is typically only offered after several failed medication trials/repeated hospitalizations), it is a very effective treatment. It is very safe and is not painful. The patient is given anesthesia and a muscle relaxant for the procedure. For some patients, ECT is safer than medications, particularly for those with serious medical conditions for whom medication can be contraindicated and for pregnant woman who may not want to expose the fetus to a certain medication (e.g., lithium). ECT is growing in use in older depressed patients because of higher rates of concurrent medical illness and risks of toxicity from medication. Psychotic depressions are often refractory to medication, and thus, ECT may be considered early on in the treatment to avoid a prolonged course of medication trials.
The risk of serious complication from ECT is 1 in 1,000. Cardiac complications are the most common adverse effects, which is why a pre-ECT evaluation includes evaluation of the cardiac system. Most potential cardiovascular complications can be avoided with the use of appropriate medications. Confusion and/or memory loss are also often common. Confusion is usually transient. Memory deficits may be for events before or after the procedure. Memory deficits usually resolve over weeks to months after, although occasionally there are more persistent memory difficulties.
Although ECT provides rapid improvement in symptoms of depression, there is a high rate of relapse – up to 50% within 6 months – and thus, either continuation/maintenance ECT or medication is recommended after the treatment course. Continuation ECT is usually provided only if continuation medication has not successfully prevented relapse or recurrence of depression in the past.
ECT is usually done in a hospital setting as an inpatient (outpatient ECT may be provided for maintenance ECT). Medications are typically tapered and discontinued before the treatment, and this process may need to occur in a hospital setting because of the risk for worsening depression and/or suicidal. ECT providers have received specialized training and certification. Although protocols may vary from state to state, usually more than one physician needs to evaluate the patient and determine that ECT is clinically appropriate.
Unfortunately, because of the media’s negative portrayal of ECT over the years, even with the safety features in place, this very effective procedure is highly stigmatized and even illegal in some jurisdictions.